Tag Archives: ventilators

(Reuters) – On the final Thursday in March the Arkansas team in charge of procuring ventilators thought they had scored a coup: a vendor had agreed to sell them 500 of the breathing machines critical to keeping COVID-19 patients alive at $19,000 each.

The next day they were told the deal had vanished because a buyer representing New York was offering to purchase 10,000 units, pay cash upfront and double the price, a deal the vendor could not turn down. Reuters could not independently verify that New York bought the ventilators.

Either way, for Arkansas, the search for the machines goes on.

“We still want to purchase the 500,” said Dr. Steppe Mette, chief executive of UAMS Medical Center in Little Rock, who is helping oversee procurement of supplies for the state. “There are profiteers all over the place.”

Arkansas may never need those ventilators. It has 785 across the state, most of which are not currently in use, and data from New York and other hot spots in recent days suggest hospitalizations might be peaking.

In the past week Louisiana and Arizona scaled back their requests for ventilators from the federal government, while Oregon, Washington and California offered up spare units for use by other states.

But the episode illustrates how some states have been muscled aside in the scramble for equipment to combat a virus that has killed nearly 18,000 people in the United States, potentially leaving them vulnerable should the worst-case scenarios materialize or the virus return in subsequent waves.

The stakes are especially high when it comes to ventilators, which can be the difference between life or death for patients suffering from COVID-19, the respiratory illness caused by the novel coronavirus.

Reuters surveyed all 50 states about their ventilator needs. The 31 that either responded or have disclosed figures showed a collective intent to procure 70,000 units, including outstanding requests to the federal government and private sector.

The Federal Emergency Management Agency (FEMA) has acknowledged there aren’t enough ventilators in the Strategic National Stockpile to meet demand, and is distributing units to states most in need. According a FEMA spokesperson, the federal government has 8,644 ventilators available, including 8,044 in the stockpile and 600 from the Department of Defense.

Some states have criticized the federal government for crowding them out of the market. Rhode Island, which has 300 ventilators, one of the lower inventories among the states, said it is struggling to source the machines.

Arkansas’ Mette said his procurement team had tried to buy the Shangrila 510S, a compact ventilator advertised on the website of the manufacturer, Beijing Aeonmed Co. Ltd. as “Ready to Confront COVID-19”, from a reseller of the machines.

The incident was significant enough that a report was given to Governor Asa Hutchinson, portions of which were read to Reuters. It says the order vanished in a matter of hours after buyers for New York secured a deal for 10,000 units, the maximum that could be produced in two months.

The office of New York Governor Andrew Cuomo did not respond to a request for comment. Cuomo has himself complained about receiving only 2,500 out of an order for 17,000 ventilators from China, with per-unit prices doubling since the outbreak.

Beijing Aeonmed said it had not applied for approval from the U.S. Food & Drug Administration (FDA) for the Shangrila 510S and that producing 10,000 units in such a short time was “unrealistic”.

Roger Biles, the head of a medical supplies company, InterMed Resources TN, helping Arkansas source ventilators from China, said the reseller told them it was New York that had bought the machines but there was no way to know for sure.

“If you snooze you lose in this environment. Product is going left and right,” Biles said. “We couldn’t get the money to them fast enough. They said they are all gone.”

Biles said the reseller provided certification that the Shangrila 510S could be sold in the United States because it had similar specifications to an approved machine, a common process to gain market access. The FDA did not respond to a request for comment.

The administration of President Donald Trump is working with Ford Motor Co and other manufacturers to produce 100,000 ventilators by the end of June, and FEMA has told states it will provide units 72 hours before any surge hits them.

Arkansas still wants a buffer, even with current projections showing it may now only need 300 ventilators at the apex of hospitalizations in the coming weeks, whereas a previous model indicated it may require 2,000 at peak.

“Prepare for the worst, hope for the best. We are still going on that philosophy,” Mette said.

(Reporting by Nathan Layne in Wilton, Connecticut and Roxanne Liu in Beijing; Editing by Paul Thomasch and Daniel Wallis)

NEW YORK (Reuters) – The number of U.S. coronavirus infections climbed above 82,000 on Thursday, surpassing the national tallies of China and Italy, as New York, New Orleans and other hot spots faced a surge in hospitalizations and looming shortages of supplies, staff and sick beds.

With medical facilities running low on ventilators and protective masks and hampered by limited diagnostic testing capacity, the U.S. death toll from COVID-19, the respiratory disease caused by the virus, rose beyond 1,200.

“Any scenario that is realistic will overwhelm the capacity of the healthcare system,” New York Governor Andrew Cuomo told a news conference. He described the state’s projected shortfall in ventilators – machines that support the respiration of people have cannot breathe on their own – as “astronomical.”

“It’s not like they have them sitting in the warehouse,” Cuomo added. “There is no stockpile available.”

At least one New York City hospital, New York-Presbyterian/Columbia University Medical Center in Manhattan, has begun a trial of sharing single ventilators between two patients.

While New York was the coronavirus epicenter in the United States this week, the next big wave of infections appeared headed for Louisiana, where demand for ventilators has already doubled. In New Orleans, the state’s biggest city, Mardi Gras celebrations late last month are believed to have fueled the outbreak.

Louisiana Governor John Bel Edwards said New Orleans would be out of ventilators by April 2 and potentially out of bed space by April 7 “if we don’t flatten the infection curve soon.”

“It’s not conjecture, it’s not some flimsy theory,” Edwards told a press conference. “This is what is going to happen.”

Nurse Tina Nguyen administers a nasal swab at a coronavirus testing site outside International Community Health Services in the Chinatown-International District during the coronavirus disease (COVID-19) outbreak in Seattle, Washington, U.S. March 26, 2020. REUTERS/Lindsey Wasson

About 80% of Louisiana’s intensive care patients are now on breathing machines, up from the normal rate of 30-40%, said Warner Thomas, chief executive of Ochsner Health System, the state’s hospital group.

Scarcities of protective masks, gloves, gowns and eyewear for doctors and nurses – reports abound of healthcare workers recycling old face masks, making their own or even using trash bags to shield themselves – have emerged as a national problem.

“Our nurses across the country do not have the personal protective equipment that is necessary to care for COVID patients, or any of their patients,” Bonnie Castillo, head of the largest U.S. nurses union, National Nurses United, told MSNBC.

In an ominous milestone for the United States as a whole, at least 82,153 people nationwide were infected as of Thursday, according to a Reuters tally from state and local public health agencies. China, where the global pandemic emerged late last year, had the second highest number of cases, 81,285, followed by Italy with 80,539.

At least 1,204 Americans have died from COVID-19, which has proven especially dangerous to the elderly and people with underlying chronic health conditions, Reuters’ tally showed.

MORE BEDS NEEDED

For New York state, Cuomo said a key goal was rapidly to expand the number of available hospital beds from 53,000 to 140,000.

New York hospitals were racing to comply with Cuomo’s directive to increase capacity by at least 50%. At Mount Sinai Hospital’s Upper East Side location, rooms were being constructed within an atrium to open up more space for beds.

At Elmhurst Hospital in New York’s borough of Queens, about a hundred people, many wearing masks with their hoods pulled up, lined up behind barriers outside the emergency room entrance, waiting to enter a tent to be screened for the coronavirus.

The city coroner’s office has posted refrigerated trucks outside Elmhurst and Bellevue Hospital to temporarily store bodies of the deceased.

Deborah White, vice chair of emergency medicine at Jack D. Weiler Hospital in the city’s Bronx borough, said 80% of its emergency room visits were patients with coronavirus-like symptoms.

A ventilator shortfall and surge in hospitalizations has already raised the prospect of rationing healthcare.

Asked about guidelines being drafted on how to allocate ventilators to patients in case of a shortage, New Jersey Governor Phil Murphy told reporters such bioethical discussions “haunted him” but were unavoidable.

Outside New York and New Orleans, other hot spots appeared to be emerging around the country, including Detroit.

Brandon Allen, 48, was buying groceries in Detroit for his 72-year-old mother, who has tested positive and was self-quarantining at home.

“It’s surreal,” Allen said. “People around me I know are dying. I know of a couple people who have died. I know a couple of people who are fighting for their lives. Everyday you hear of another person who has it.”

RECORD UNEMPLOYMENT CLAIMS

Desperate to slow virus transmissions by limiting physical contact among people, state and local governments have issued stay-at-home orders covering about half the U.S. population. A major side effect has been the strangulation of the economy, and a wave of layoffs.

The U.S. Labor Department reported Thursday the number of Americans filing claims for unemployment benefits last week soared to a record of nearly 3.28 million – almost five times the previous weekly peak of 695,000 during the 1982 recession.

Dr. Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, said warmer weather may help tamp down the U.S. outbreak as summer approaches, though the virus could re-emerge in the winter.

“We hope we get a respite as we get into April, May and June,” Fauci said on WNYC public radio.

Washington state Governor Jay Inslee said he may extend a stay-at-home order tentatively set to expire April 6, encouraged by what he called a “very modest improvement” in the Seattle area.

Washington experienced the first major U.S. outbreak of COVID-19 and has been among the hardest-hit states. As of Thursday the state reported about 3,200 cases and 147 deaths.

In California’s Coachella Valley, a region rife with retirees who are especially vulnerable, 25 members of the state’s National Guard helped a non-profit distribute food to people stuck in their homes, as most of the regular volunteers are senior citizens.

More than 10,000 troops have been deployed in 50 states to provide humanitarian aid during the pandemic.

NEW YORK/WASHINGTON (Reuters) – U.S. governors and mayors on Monday became more desperate in their pleas for help from the federal government to fight coronavirus as the military prepared to set up field hospitals in New York and Seattle to ease the strain on creaking health services.

New York City Mayor Bill de Blasio urged U.S. lawmakers to approve an economic relief package and appealed for ventilators and medical equipment, even asking for help from private citizens.

“Anyone out there who can help us get these supplies, we have only days to get them in place. That is the reality,” de Blasio told CNN. New York, the most populous U.S. city, is now at the epicenter of the outbreak in the United States.

Karine Raymond, a nurse at Jack D. Weiler Hospital in New York’s Bronx borough, said most nurses were unable to get specialized N95 masks and even simpler surgical masks were in short supply. Nurses are being told to wear them for as long as possible, she said.

“We are the be all and end all and lifeline to these patients, and yet we are being contaminated and cross contaminating,” Raymond said.

As health authorities struggled to cope with the rising number of sick people and the U.S. Senate failed to advance an economic stimulus package, Defense Secretary Mark Esper said the U.S. military is preparing to deploy field hospitals to New York and Seattle.

The planned hospitals, essentially tent facilities that can be rapidly set up, can only handle a limited number of patients and are less suited to treating highly infectious people who need to be isolated. But they can relieve pressure on hospitals by treating patients with illnesses other than COVID-19.

The Army Corps of Engineers is preparing to convert hotels and dormitories into treatment facilities for sick patients as the number of U.S. coronavirus cases nationwide topped 40,000 on Monday, more than 500 of whom have died.

New York’s de Blasio urged U.S. lawmakers to provide more help.

“I want to appeal to everyone in the House and Senate, you have got to help cities, towns, countries, states, public hospitals, private hospitals. You’ve got to get all of them direct relief,” he said.

A far-reaching economic package for the coronavirus crisis failed to advance in the Senate after Democrats said it contained too little money for hospitals and not enough restrictions on a fund to help big businesses. Democrats predicted a modified version would win passage soon.

Both Democrats and Republicans say they are aware that failure to agree on the bill could have a devastating effect on states, cities and businesses, and trigger further heavy losses in U.S. stock markets.

The U.S. Federal Reserve rolled out an unprecedented new array of programs aimed at blunting the “severe disruptions” to the economy caused by the coronarvirus outbreak.

The central bank will back the purchases of corporate bonds and direct loans to companies. It will expand its asset holding by as much as needed to stabilize financial markets and roll out a program to get credit to small and medium-sized business.

The steps briefly lifted U.S. stock index futures more than 3% but share prices quickly dropped back into the red, putting the S&P 500 <.SPX> on pace for its worst month since World War Two.

With the addition of Maryland, Indiana, Michigan and Massachusetts on Monday, 15 out of 50 U.S. states have now imposed restrictions on people’s movements to curtail the virus, putting the country on a track similar to those of the most devastated European countries such as Italy and Spain.

The population affected by the state lockdowns amounts to more than 150 million people out of a U.S. total of about 330 million.

STAY AT HOME

In what appeared to send a conflicting message about the federal government’s efforts to combat the coronavirus health crisis, a senior White House advisor said that President Donald Trump is considering measures to reopen the U.S. economy.

Trump issued guidelines a week ago that he said aimed to slow the spread of the disease over 15 days. Late on Sunday, he tweeted: “We cannot let the cure be worse than the problem itself,” adding that at the end of the 15-day shutdown period, “we will make a decision as to which way we want to go.”

Trump senior economic adviser Larry Kudlow followed up on Monday, telling Fox News: “The president is right … We’re going to have to make some difficult trade-offs.”

A lack of coordinated federal action was causing chaos for states and municipalities, and even putting them in competition with each other for resources, the governors of New York, New Jersey and Illinois said.

The states “are all out looking for the same thing,” New Jersey Governor Phil Murphy told CNN on Monday.

Leaving states to fend for themselves has put them in bidding wars with the Federal Emergency Management Agency, other U.S. states and even against other countries, Illinois Governor J.B. Pritzker said.

“We’re competing against each other on what should be a national crisis where we should be coming together and the federal government should be leading, helping us,” Pritzker told the “Today” program.

New York Governor Andrew Cuomo called on Washington to put in place the federal defense production act to eliminate this “ad hoc” system. Trump on Sunday defended his decision to hold off using this power, on the grounds that nationalizing businesses “is not a good concept.”

General Motors Co <GM.N> and medical equipment maker Ventec are speeding up efforts under a partnership code-named “Project V” to build ventilators at a GM plant in Kokomo, Indiana, to help combat the coronavirus outbreak.

Ford, GM, Tesla getting ‘go ahead’ to make ventilators: Trump
WASHINGTON (Reuters) – U.S. President Donald Trump said on Sunday that U.S. automakers Ford Motor Co, General Motors Co and Tesla Inc had been given the green light to produce ventilators and other items needed during the coronavirus outbreak.

“Ford, General Motors and Tesla are being given the go ahead to make ventilators and other metal products, FAST! @fema Go for it auto execs, lets see how good you are?” he said on Twitter.

NEW YORK (Reuters) – The mayor of New York City, the epicenter of the nation’s coronavirus epidemic, on Sunday described the outbreak as the biggest domestic crisis since the Great Depression and called for the U.S. military to mobilize to help keep the healthcare system from becoming overwhelmed.

“If we don’t get more ventilators in the next 10 days people will die who don’t have to die,” said Mayor Bill de Blasio, as the nation’s most populous city saw COVID-19 cases top 8,000 and deaths hit 60.

Nationwide, cases have topped 29,000 with at least 385 dead, according to a Reuters tally. The number of cases of the highly contagious respiratory illness in the United States and Spain are exceeded only by China and Italy. Italy reported record numbers of daily coronavirus deaths last week.

“This is going to be the greatest crisis domestically since the Great Depression,” de Blasio told CNN, referring to the economic crisis of the 1930s. “This is why we need a full-scale mobilization of the American military.”

Nearly one in four Americans, or 80 million, were under orders to shelter at home as New York, California, Illinois, Connecticut and New Jersey instituted statewide lockdowns.

Around the globe, billions are adapting to a new reality, with countries like Italy, Spain and France on lockdown and several South American nations taking similar measures to try to stay ahead of the contagion, as global cases exceeded 300,000 and deaths top 13,000.

The lockdown affecting large segments of the American public to try to curb the spread of the coronavirus is likely to last 10 to 12 weeks, or until early June, U.S. Treasury Secretary Steven Mnuchin said on Sunday.

Lawmakers in Washington are nearing a deal that could pump a record $1 trillion into the economy to limit the economic damage from the coronavirus.

Speaking on “Fox News Sunday,” Mnuchin said the package would give an average U.S. family of four a one-time payment of $3,000.

MEDICAL CRISIS

De Blasio said the city is not getting needed medical supplies from the federal government to contend with the rapid spread of the sometimes deadly illness.

“If the president does not act, people will die who could have lived otherwise,” de Blasio told NBC.

Hospitals are scrambling for protective equipment for healthcare workers and for ventilators as they brace for a wave of patients who will need help breathing as severe cases often lead to pneumonia and decreased lung function.

New York Governor Andrew Cuomo urged the federal government to take over acquisition of medical supplies so states do not have to compete with each other for desperately needed resources. He also repeated a request for the Army Corps of Engineers to build temporary hospitals.

Over the past week, U.S. President Donald Trump’s administration has been pushing for aggressive steps to stem the economic hit, after Trump spent several weeks downplaying the virus’ risks.

Trump said on Twitter on Sunday that U.S. automakers Ford Motor Co, General Motors Co and Tesla Inc had been given the green light to produce ventilators and other items in short supply during the coronavirus outbreak.

Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, on Sunday said the White House recognized the urgency of New York’s situation.

“Not only is New York trying to get resources themselves, but we’re going to be pouring it in from the federal government,” he told CBS News.

U.S. drugmaker Merck & Co Inc said it delivered 500,000 donated masks to New York City on Sunday morning.

The help is not coming quickly enough, Cuomo said.

“Time matters, minutes count, and this is literally a matter of life and death,” he said.

He also chastised New York residents who were congregating in parks and other places and not practicing social distancing. He noted 53% of the cases in New York are between the ages of 18 and 49.

“It’s insensitive, arrogant, self-destructive…and it has to stop, and it has to stop now,” he said. “This is not a joke and I’m not kidding.”

(Reporting by Jonnelle Marte and Barbara Goldberg in New York; Additional reporting by Andrea Shalal and Susan Heavey in Washington; Writing by Lisa Shumaker; Editing by Bill Berkrot)

LOS ANGELES/NEW YORK (Reuters) – New York and Illinois on Friday followed California in telling tens of millions of people to stay at home in the most sweeping measures the United States has taken so far to try to contain the coronavirus crisis.

The moves, which impact more than 70 million people or about a fifth of the U.S. population, close all but essential businesses and require people to stay inside except for trips to grocery stores, pharmacies, gas stations and other “essential businesses.”

New Jersey Governor Phil Murphy said he planned to give similar orders shutting down all but essential businesses within the next 24 hours.

“To avoid the loss of tens of thousands of lives we must order an immediate shelter-in-place,” Illinois Governor J.B. Pritzker said on Friday, using a term that has commonly referred to mass shootings. Illinois includes Chicago.

The four states where governors have banned or will soon ban non-essential businesses and ask residents to stay home account for about 30% of the U.S. economy, the world’s biggest.

In New York City’s Central Park, several bikers and joggers were on the pathways, mostly alone but a few in pairs.

“It’s real and it’s scary, I hate it,” said physical therapist Kerry Cashin, 49, of the stay-at-home order. “I feel like I always knew it was going to go this way, but it made me scared.”

Just two dozen people milled outside Hollywood’s Dolby Theatre in Los Angeles, the home of the Oscars, an area normally teeming with hundreds of tourists.

Zane Alexander, 27, said he was on his way to pick up his last paycheck “until lord knows when.” He had been working on a medical marijuana dispensary’s street team, a job that normally had him outside, but that team was disbanded until further notice.

Retiree Jerry Rasmussen, 73, sat on a sunny public bench reading the San Francisco Chronicle in the city’s central neighborhood of Cole Valley, with hand sanitizer, gloves and a mask beside him.

“I figure being outdoors like this is pretty safe, as long as I’m not too close to anyone,” he said.

VENTILATORS NEEDED

Cuomo, in making his stay-at-home announcement, pleaded for more medical personnel and supplies such as ventilators and protective masks to treat coronavirus cases that could overwhelm the hospitals in his state of nearly 20 million.

“The ventilators are to this war what missiles were to World War Two,” Cuomo said. He said the state would “pay a premium” to companies that could provide more personal protective equipment, gloves and masks. He asked companies that might be capable of making these products to “get creative.”

Cuomo issued an executive order mandating all non-essential workforce to stay home and all non-essential businesses to close.

“Remain indoors, go outside for solitary exercise,” he said.

The pandemic that has swept the globe has also shattered lifestyles across much of the United States in the past week, shuttering schools and businesses, prompting millions to work from home, forcing many out of jobs and curtailing travel.

The health orders imposed on Thursday by California authorities on the state’s 40 million people allow for outside exercise as long as people stay six feet apart.

“We need to take it really seriously and prevent spread of the disease,” said venture capitalist Meredith Finn, 37, while walking her dog Brady in the affluent West Los Angeles neighborhood of Brentwood. “It’s definitely the right move.”

More than 1,000 cases have been confirmed in California, where 19 people have died. New York officials said the state has 7,102 confirmed cases and of those, 4,408 are in New York City, the most populous U.S. city with about 8.5 million people. Thirty-eight have died in the state.

Washington state, where the first U.S. coronavirus cluster emerged, has since March 16 closed bars, restaurants and recreation and entertainment facilities, and has banned all gatherings of more than 50 people.

More than 220 people have died in the United States and over 14,100 cases had been confirmed by Friday afternoon, the surge in cases reflecting an increase in testing. Health experts believe the actual number of COVID-19 cases to be far higher.

In Washington, D.C., President Donald Trump and other officials told reporters the United States was working with Mexico to suspend non-essential travel at the border. The border with Canada already is closed to non-essential traffic.

With businesses closing and daily life grinding to a near halt, and the U.S. unemployment benefits program about to face its biggest test in more than a decade, the Trump administration announced more moves to give relief to workers and students. Tax filing day was moved to July 15 from April 15, while interest and payments on federal student loans were suspended for at least the next 60 days.

EMS, Switzerland (Reuters) – Britain faces a “massive shortage” of ventilators that will be needed to treat critically ill patients suffering from coronavirus, after it failed to invest enough in intensive care equipment, a leading ventilator manufacturer said on Wednesday.

“England is very poorly equipped,” said Andreas Wieland, chief executive of Hamilton Medical in Switzerland, which says it is the world’s largest ventilator maker.

“They’re going to have a massive shortage, once the virus really arrives there,” he told Reuters in an interview.

Ventilators, running in the thousands of dollars per unit, are used to help people with respiratory difficulties to breathe. They are high-tech versions of the “iron lungs” that kept people alive into the 1950s during fierce polio epidemics.

Worldwide, the devices have become shorthand for the rapid advance of the disease — and the desperation of officials who fear their stocks are inadequate. New York Gov. Andrew Cuomo said the 3,000 devices in his state where 20 people have died are a fraction of what he’d like to have.

“The entire world is trying to buy ventilators,” Cuomo said, according to a transcript published on Wednesday, adding he is hoping to tap a U.S. federal government stockpile.

Germany’s Draegerwerk last week got a government order for 10,000, equal to a typical year’s production.

Wieland’s company in the Swiss Alps has boosted normal production of some 15,000 ventilators annually by 30-40% and now can produce about 80 ventilators daily.

He has shifted his 1,400 employees to seven-day work weeks as well as borrowed workers from other companies in the Rhine River valley where his two-year-old ventilator plant is located.

Last week, Hamilton Medical shipped 400 ventilators to Italy, whose intensive care units have been overwhelmed by more than 35,000 cases of the rapidly spreading virus and almost 3,000 deaths.

About 50% of those with coronavirus in Italy accepted into intensive care units are dying, compared with typical mortality rates of 12% to 16% in such units.

Wieland said a similar outbreak in Britain, now with more than 2,600 cases and about 100 deaths, would swamp the system there, too.

“They are not well equipped with ventilators and intensive care stations,” he said. “They invested very little, and I think now they will pay the price.”

“We think we need many times more than that and we are saying if you produce a ventilator then we will buy it,” he said earlier this week. “No number is too high.”

Wieland said he was in “close contact” with UK medical leaders and aimed to prioritize shipments there soon, though for now Italy was taking precedence.

But he also has orders from the United States, Turkey, France and China, where in January he stocked up on components in anticipation of rising demand as the virus spread from its origins in Wuhan.

The UK’s Intensive Care Society, an organization of medical professionals, did not immediately return emails and phone calls from Reuters seeking comment on the nation’s readiness for a possible explosion of coronavirus cases.

“We are likely to need more,” a National Health Service spokesman told Reuters. “Engineers have already been tasked with developing plans to produce more ventilators in the UK, at speed.”

Hamilton CEO Wieland is skeptical, however, of the British government’s recent call for manufacturers from other industries including Ford, Honda and Rolls Royce to help make equipment including ventilators.

“I wish them the best of luck,” Wieland said. “I do not believe anything will come of it. These devices are very complex. It takes us four to five years” to develop a new product.

(Reporting by John Miller in Ems, Andrew MacAskill in London; Editing by Mark Potter and Chizu Nomiyama)